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Interhemispheric subdural hematoma caused by a ruptured internal carotid artery aneurysm: Case report
Hematoma
Interhemispheric Subdural Hematoma Caused by a Ruptured Internal Carotid Artery Aneurysm: Case Report Eiichi Ishikawa, M.D.,* Koichi Sugimoto, M.D.,* Kiyoyuki Yanaka, M.D., Ph.D.,† Satoshi Ayuzawa, M.D., Ph.D.,* Masahiro Iguchi, M.D.,* Takashi Moritake, M.D.,* Eiki Kobayashi, M.D., Ph.D.,* and Tadao Nose, M.D., Ph.D.† *Departments of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan, and †Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
Ishikawa E, Sugimoto K, Yanaka K, Ayuzawa S, Iguchi M, Moritake T, Kobayashi E, Nose T. Interhemispheric subdural hematoma caused by a ruptured internal carotid artery aneurysm. Case report. Surg Neurol 2000;54:82– 6.
due to a ruptured aneurysm arising from the internal carotid-posterior communicating artery (IC-PC) junction.
BACKGROUND
Interhemispheric subdural hematoma (ISH) usually occurs after head trauma; nontraumatic ISH is extremely rare. CASE DESCRIPTION
The authors describe a 62-year-old male presenting with severe headache and ptosis on the left side. Computed tomography (CT) and magnetic resonance imaging disclosed a hematoma in the interhemispheric subdural space without subarachnoid hemorrhage. Cerebral angiography revealed an aneurysm arising from the left internal carotid-posterior communicating artery (IC-PC) junction. The patient underwent emergency clipping of the aneurysm and was discharged without neurological deficit. CONCLUSION
Ruptured aneurysms resulting in ISH without subarachnoid hemorrhage have been reported in only a few cases; this is the second case to describe the association of a ruptured IC-PC aneurysm with an ISH. The etiology of ISH formation due to ruptured aneurysms and the diagnosis are discussed. © 2000 by Elsevier Science Inc. KEY WORDS
Cerebral aneurysm, interhemispheric subdural hematoma, internal carotid artery.
nterhemispheric subdural hematoma (ISH) is a relatively uncommon type of acute subdural hematoma, and its nontraumatic pathogenesis is extremely limited. The authors describe a case of ISH
I
Address reprint requests to: Eiichi Ishikawa, Department of Neurosurgery, Tsukuba Memorial Hospital, Kaname 1187-299, Tsukuba, Ibaraki 300-2622, Japan. Received February 16, 2000; accepted May 22, 2000. 0090-3019/00/$–see front matter PII S0090-3019(00)00262-7
Case Report A 62-year-old hypertensive male experienced a sudden severe headache and dizziness. There was no history of head or neck trauma and the patient had no history of sudden onset headaches. The patient was admitted to a community hospital 2 days after the onset of the symptoms and computed tomography (CT) scan revealed interhemispheric hyperdensity over the tentorium cerebelli and along the posterior falx (Figure 1). He underwent conservative treatment, but his severe headache showed no improvement. The patient was referred to our hospital 10 days after the onset of symptoms for further investigation and treatment. On admission, the patient was alert and showed a left ptosis. He complained of severe headache without neck stiffness. CT and magnetic resonance (MR) imaging (Figures 2, 3) disclosed the ISH on the left side of the posterior falx. Cerebral angiography revealed an aneurysm arising from the left IC-PC junction (Figure 4). Emergency surgery was performed to clip the aneurysm. The cerebrospinal fluid was not xanthochromic in the basal cisterns. The aneurysm was directed posterolaterally and attached to the upper surface of the tentorium cerebelli, as seen on postcontrast CT (Figure 5). The top of the fundus was covered by the overlying temporal lobe, so the condition around the fundus of the aneurysm could not be observed. However, the fundus of the aneu© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Interhemispheric SDH and ICPC Aneurysm
1
83
Computed tomography showing a high-density area between the tentorium cerebelli and posterior interhemispheric space. No subarachnoid hemorrhage is seen.
rysm did not move after clipping of the aneurysmal neck, suggesting adhesion of the fundus to the adjacent leptomeninges. After clipping the aneurysm, the ISH was irrigated with saline. The postoperative
2
Surg Neurol 2000;54:82–6
course was uneventful, and a CT scan demonstrated diminution of the ISH. The patient was discharged from our hospital without any neurological deficits.
Posterior interhemispheric subdural hematoma showing high intensity on T1-weighted (left) and T2-weighted images.
84
3
Surg Neurol 2000;54:82–6
Ishikawa et al
Coronal T1-weighted magnetic resonance imaging showing a subdural hematoma extending from the upper surface of the tentorium cerebelli to the interhemispheric fissure.
DISCUSSION The incidence of acute subdural hematoma (ASDH) due to a ruptured aneurysm is well documented in
the literature [12], and it occurs in 0.5% to 7.9% of all cases [1,3,5,6,11,14,16]. Two mechanisms for the development of ASDH due to ruptured aneurysms have been proposed. First, successive small bleed-
Cerebral angiography showing an aneurysm arising from the left internal carotid-posterior communicating artery junction. Note the aneurysm is directed posterolaterally (left; anterior-posterior view, center; lateral view, right; left-anterior oblique view).
4
Interhemispheric SDH and ICPC Aneurysm
Surg Neurol 2000;54:82–6
Post-contrast computed tomography showing attachment of the fundus of the aneurysm to the tentorium cerebelli.
5
ing episodes cause adhesion of the aneurysm to the adjacent arachnoid membrane, and the final rupture occurs into the subdural space. Second, a hemorrhage under high pressure may lead to piaarachnoid rupture [4,6,9]. Several cases with ASDH due to ruptured IC-PC aneurysms have been reported [4,5,8,9,11,13]. Most of the documented cases were of saccular aneurysms directed posterolaterally, and the ASDHs were observed mainly at the convexity. Ishibashi et al reported a case of a ruptured IC-PC aneurysm causing an ASDH at the convexity without subarachnoid hemorrhage [8]. They observed the adhesion of the fundus of the aneurysm to the tentorium cerebelli [8] and thought that this adhesion, caused by a previous hemorrhage, was the mechanism for the direct
1
AUTHOR/YEAR
AGE/ SEX
1
Friedman et al/1983
55/F
2
Watanabe et al/1991 51/M Semicoma
4 5
hemorrhage into the subdural space. The aneurysm in our case was directed posterolaterally and attached to the upper surface of the tentorium cerebelli. Our patient had no history of previous hemorrhage and the condition around the fundus of the aneurysm could not be observed during surgery. However, from radiological and surgical points of view, rupture with the preceding adhesion of the aneurysm to the adjacent leptomeninges may have resulted in a hemorrhage into the subdural space. ISH usually occurs after head trauma and its spontaneous or non-traumatic occurrence is extremely rare [2,6,17]. Ruptured aneurysms resulting in ISH with no subarachnoid hemorrhage have been reported in only four cases [6,7,15]. All cases including ours are summarized in Table 1. Three of five patients had an aneurysm at the distal anterior cerebral artery (ACA) [7,15], and the remaining two had aneurysms at the IC-PC junction [6]. A distal ACA aneurysm can easily bleed into the interhemispheric space, but it seems difficult for blood from IC-PC aneurysms to drain directly into the interhemispheric space. The two cases with IC-PC aneurysms (No. 1 and No. 5) also had clots over the tentorium cerebelli, and these clots were thought to be located in the interhemispheric subdural space. All patients underwent clipping of the aneurysm [6,7,15], and hematoma evacuation was done in three of them. Aneurysmal neck clipping or other treatments for the aneurysm should be done before treatment for ISH when the ISH is thin and causes no neurological deficit. However, patients with disturbed consciousness due to massive ISH should be treated for the ISH immediately. Thus, for the differential diagnosis of ISH we should rule out a ruptured aneurysm, especially in the absence of head trauma. Continuity between a convexity subdural hematoma and an ISH has been
Summary of Cases of Interhemispheric Subdural Hematoma Without Subarachnoid Hemorrhage Caused by Ruptured Aneurysms
CASE NO.
3
85
INITIAL SYMPTOM Headache
SITE OF ANEURYSM
ASSOCIATED HEMATOMA
Lt. IC-PC
Tentorium cerebelli Lt. distal ACA Lt. convexity
TREATMENT Clipping
Hematoma evacuation Hatayama et al/1994 55/M Semicoma Rt. distal ACA Rt. convexity Clipping, hematoma evacuation 66/F Semicoma Lt. distal ACA Bil. convexity Clipping, hematoma evacuation present case 2000 62/M Headache, ptosis Lt. IC-PC Tentorium Clipping cerebelli
IC-PC: internal carotid-posterior communicating artery bifuration; ACA: anterior cerebral artery.
OUTCOME Good Death Good Good Good
86
Surg Neurol 2000;54:82–6
Ishikawa et al
reported to indicate a ruptured aneurysm of the distal ACA on CT [8,15]. In contrast, continuity between a tentorial hematoma and an ISH may indicate a ruptured aneurysm of the IC-PC junction [7]. The possibility of aneurysmal subdural hematoma should be considered in the absence of trauma.
13.
14.
REFERENCES 1. Ban S, Sato S, Yamamoto T, Ogata M. Distal anterior cerebral aneurysms causing acute subdural hematoma: report of two cases. Neurol Surg 1985;13:911– 6. 2. Bartels RHMA, Verhagen WIM, Prick MJJ, Dalman JE. Interhemispheric subdural hematoma in adults: case report and a review of the literature. Neurosurgery 1995;36:1210 – 4. 3. Bassett RC, Lemmen LJ. Subdural hematoma associated with bleeding intracranial aneurysm. J Neurosurg 1952;9:443–50. 4. Clarke E, Walton JN. Subdural hematoma complicating intracranial aneurysm and angioma. Brain 1953; 76:378 – 404. 5. Eggers FM, Tomsick TA, Lukin RR, Chambers AA. Recognition of subdural hematoma secondary to ruptured aneurysm by computed tomography. Comput Radiol 1982;6:309 –13. 6. Friedman MB, Brant-Zawadzki M. Interhemispheric subdural hematoma from ruptured aneurysm. Comput Radiol 1983;7:129 –34. 7. Hatayama T, Shima T, Okada Y. Ruptured distal anterior cerebral artery aneurysm presenting with acute subdural hematoma: report of two cases. Neurol Surg 1994;22:577– 82. 8. Ishibashi A, Yokokura Y, Sakamoto M. Acute subdural hematoma without subarachnoid hemorrhage due to ruptured intracranial aneurysm— case report. Neurol Med Chir (Tokyo) 1997;37:533–7. 9. Kondziolka D, Bernstein M, Brugge K, Schutz H. Acute subdural hematoma from ruptured posterior communicating artery aneurysm. Neurosurgery 1988;22: 151– 4. 10. McLaughlin MR, Jho H-D, Kwon Y. Acute subdural hematoma caused by a ruptured giant intracavernous aneurysm: case report. Neurosurgery 1996;38:388 –92. 11. O’Sullivan MG, Whyman M, Steers JW, Whittle IR, Miller JD. Acute subdural haematoma secondary to ruptured intracranial aneurysm: diagnosis and management. Br J Neurosurg 1994;8:439 – 45. 12. Pasqualin A, Bazzan A, Cavazzani P, Scienza R, Licata
15.
16.
17.
C, Pian RD. Intracranial hematomas following aneurysmal rupture: experience with 309 cases. Surg Neurol 1986;25:6 –17. Ranganadham P, Dinakar I, Mohandas S, Singh AK. A rare presentation of posterior communicating artery aneurysm. Clin Neurol Neurosurg 1992;94:225–7. Serizawa T, Satoh A, Kobayashi S, Nakamura H, Odaki M, Miyata A, Watanabe Y. Three cases of nontraumatic acute subdural hematoma. Neurol Surg 1991;19:1061–5. Watanabe K, Wakai S, Okuhata S, Nagai M. Ruptured distal anterior cerebral artery aneurysms presenting as acute subdural hematoma—report of three cases. Neurol Med Chir (Tokyo) 1991;31:514 –7. Weir B, Myles T, Kahn M, Maroun F, Malloy D, Benoit B, McDermott M, Cochrane D, Mohr G, Ferguson G, Durity F. Management of acute subdural hematomas from aneurysmal rupture. Can J Neurol Sci 1984;11: 371– 6. Zimmerman RD, Russell EJ, Yurberg E, Leeds NE. Falx and interhemispheric fissure on axial CT: II. Recognition and differentiation of interhemispheric subarachnoid and subdural hemorrhage. AJNR 1982;3:635– 42.
COMMENTARY
The authors are to be complimented for bringing to the readership’s attention a very unusual circumstance. This patient suffered acute hemorrhage from an irregular posterior communicating artery aneurysm that resulted in a subdural hematoma along the tentorium and falx. Angiographically, this aneurysm was very irregular and multi-lobulated and certainly seemed to climb up over the edge of the tentorium as depicted in the images. It certainly makes sense that adhesions of the fundus could result in acute rupture through the arachnoid directly into the subdural space. We should all keep this possibility in mind as we evaluate patients with acute symptoms and without a history of trauma. H. Hunt Batjer, M.D. Department of Neurological Surgery Northwestern University Medical School Chicago, Illinois
merican society is moving from the security of a belief in everlasting material progress (called modernism), based on the principles of Enlightenment as expressed through the successes of the capitalistic, democratic, industrialized nations, and is entering a time of confusion (called postmodernism), characterized by decreasing faith in the old principles and with no new governing paradigm readily available. Modernism has brought society many advantages, but it does not provide meaning or happiness in life.
A
—Roger J. Bulger, M.D. “The Quest for the Therapeutic Organization” JAMA 2000;283:2431–3
Interhemispheric Subdural Hematoma Caused by a Ruptured Internal Carotid Artery Aneurysm: Case Report Eiichi Ishikawa, M.D.,* Koichi Sugimoto, M.D.,* Kiyoyuki Yanaka, M.D., Ph.D.,† Satoshi Ayuzawa, M.D., Ph.D.,* Masahiro Iguchi, M.D.,* Takashi Moritake, M.D.,* Eiki Kobayashi, M.D., Ph.D.,* and Tadao Nose, M.D., Ph.D.† *Departments of Neurosurgery, Tsukuba Memorial Hospital, Tsukuba, Ibaraki, Japan, and †Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
Ishikawa E, Sugimoto K, Yanaka K, Ayuzawa S, Iguchi M, Moritake T, Kobayashi E, Nose T. Interhemispheric subdural hematoma caused by a ruptured internal carotid artery aneurysm. Case report. Surg Neurol 2000;54:82– 6.
due to a ruptured aneurysm arising from the internal carotid-posterior communicating artery (IC-PC) junction.
BACKGROUND
Interhemispheric subdural hematoma (ISH) usually occurs after head trauma; nontraumatic ISH is extremely rare. CASE DESCRIPTION
The authors describe a 62-year-old male presenting with severe headache and ptosis on the left side. Computed tomography (CT) and magnetic resonance imaging disclosed a hematoma in the interhemispheric subdural space without subarachnoid hemorrhage. Cerebral angiography revealed an aneurysm arising from the left internal carotid-posterior communicating artery (IC-PC) junction. The patient underwent emergency clipping of the aneurysm and was discharged without neurological deficit. CONCLUSION
Ruptured aneurysms resulting in ISH without subarachnoid hemorrhage have been reported in only a few cases; this is the second case to describe the association of a ruptured IC-PC aneurysm with an ISH. The etiology of ISH formation due to ruptured aneurysms and the diagnosis are discussed. © 2000 by Elsevier Science Inc. KEY WORDS
Cerebral aneurysm, interhemispheric subdural hematoma, internal carotid artery.
nterhemispheric subdural hematoma (ISH) is a relatively uncommon type of acute subdural hematoma, and its nontraumatic pathogenesis is extremely limited. The authors describe a case of ISH
I
Address reprint requests to: Eiichi Ishikawa, Department of Neurosurgery, Tsukuba Memorial Hospital, Kaname 1187-299, Tsukuba, Ibaraki 300-2622, Japan. Received February 16, 2000; accepted May 22, 2000. 0090-3019/00/$–see front matter PII S0090-3019(00)00262-7
Case Report A 62-year-old hypertensive male experienced a sudden severe headache and dizziness. There was no history of head or neck trauma and the patient had no history of sudden onset headaches. The patient was admitted to a community hospital 2 days after the onset of the symptoms and computed tomography (CT) scan revealed interhemispheric hyperdensity over the tentorium cerebelli and along the posterior falx (Figure 1). He underwent conservative treatment, but his severe headache showed no improvement. The patient was referred to our hospital 10 days after the onset of symptoms for further investigation and treatment. On admission, the patient was alert and showed a left ptosis. He complained of severe headache without neck stiffness. CT and magnetic resonance (MR) imaging (Figures 2, 3) disclosed the ISH on the left side of the posterior falx. Cerebral angiography revealed an aneurysm arising from the left IC-PC junction (Figure 4). Emergency surgery was performed to clip the aneurysm. The cerebrospinal fluid was not xanthochromic in the basal cisterns. The aneurysm was directed posterolaterally and attached to the upper surface of the tentorium cerebelli, as seen on postcontrast CT (Figure 5). The top of the fundus was covered by the overlying temporal lobe, so the condition around the fundus of the aneurysm could not be observed. However, the fundus of the aneu© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Interhemispheric SDH and ICPC Aneurysm
1
83
Computed tomography showing a high-density area between the tentorium cerebelli and posterior interhemispheric space. No subarachnoid hemorrhage is seen.
rysm did not move after clipping of the aneurysmal neck, suggesting adhesion of the fundus to the adjacent leptomeninges. After clipping the aneurysm, the ISH was irrigated with saline. The postoperative
2
Surg Neurol 2000;54:82–6
course was uneventful, and a CT scan demonstrated diminution of the ISH. The patient was discharged from our hospital without any neurological deficits.
Posterior interhemispheric subdural hematoma showing high intensity on T1-weighted (left) and T2-weighted images.
84
3
Surg Neurol 2000;54:82–6
Ishikawa et al
Coronal T1-weighted magnetic resonance imaging showing a subdural hematoma extending from the upper surface of the tentorium cerebelli to the interhemispheric fissure.
DISCUSSION The incidence of acute subdural hematoma (ASDH) due to a ruptured aneurysm is well documented in
the literature [12], and it occurs in 0.5% to 7.9% of all cases [1,3,5,6,11,14,16]. Two mechanisms for the development of ASDH due to ruptured aneurysms have been proposed. First, successive small bleed-
Cerebral angiography showing an aneurysm arising from the left internal carotid-posterior communicating artery junction. Note the aneurysm is directed posterolaterally (left; anterior-posterior view, center; lateral view, right; left-anterior oblique view).
4
Interhemispheric SDH and ICPC Aneurysm
Surg Neurol 2000;54:82–6
Post-contrast computed tomography showing attachment of the fundus of the aneurysm to the tentorium cerebelli.
5
ing episodes cause adhesion of the aneurysm to the adjacent arachnoid membrane, and the final rupture occurs into the subdural space. Second, a hemorrhage under high pressure may lead to piaarachnoid rupture [4,6,9]. Several cases with ASDH due to ruptured IC-PC aneurysms have been reported [4,5,8,9,11,13]. Most of the documented cases were of saccular aneurysms directed posterolaterally, and the ASDHs were observed mainly at the convexity. Ishibashi et al reported a case of a ruptured IC-PC aneurysm causing an ASDH at the convexity without subarachnoid hemorrhage [8]. They observed the adhesion of the fundus of the aneurysm to the tentorium cerebelli [8] and thought that this adhesion, caused by a previous hemorrhage, was the mechanism for the direct
1
AUTHOR/YEAR
AGE/ SEX
1
Friedman et al/1983
55/F
2
Watanabe et al/1991 51/M Semicoma
4 5
hemorrhage into the subdural space. The aneurysm in our case was directed posterolaterally and attached to the upper surface of the tentorium cerebelli. Our patient had no history of previous hemorrhage and the condition around the fundus of the aneurysm could not be observed during surgery. However, from radiological and surgical points of view, rupture with the preceding adhesion of the aneurysm to the adjacent leptomeninges may have resulted in a hemorrhage into the subdural space. ISH usually occurs after head trauma and its spontaneous or non-traumatic occurrence is extremely rare [2,6,17]. Ruptured aneurysms resulting in ISH with no subarachnoid hemorrhage have been reported in only four cases [6,7,15]. All cases including ours are summarized in Table 1. Three of five patients had an aneurysm at the distal anterior cerebral artery (ACA) [7,15], and the remaining two had aneurysms at the IC-PC junction [6]. A distal ACA aneurysm can easily bleed into the interhemispheric space, but it seems difficult for blood from IC-PC aneurysms to drain directly into the interhemispheric space. The two cases with IC-PC aneurysms (No. 1 and No. 5) also had clots over the tentorium cerebelli, and these clots were thought to be located in the interhemispheric subdural space. All patients underwent clipping of the aneurysm [6,7,15], and hematoma evacuation was done in three of them. Aneurysmal neck clipping or other treatments for the aneurysm should be done before treatment for ISH when the ISH is thin and causes no neurological deficit. However, patients with disturbed consciousness due to massive ISH should be treated for the ISH immediately. Thus, for the differential diagnosis of ISH we should rule out a ruptured aneurysm, especially in the absence of head trauma. Continuity between a convexity subdural hematoma and an ISH has been
Summary of Cases of Interhemispheric Subdural Hematoma Without Subarachnoid Hemorrhage Caused by Ruptured Aneurysms
CASE NO.
3
85
INITIAL SYMPTOM Headache
SITE OF ANEURYSM
ASSOCIATED HEMATOMA
Lt. IC-PC
Tentorium cerebelli Lt. distal ACA Lt. convexity
TREATMENT Clipping
Hematoma evacuation Hatayama et al/1994 55/M Semicoma Rt. distal ACA Rt. convexity Clipping, hematoma evacuation 66/F Semicoma Lt. distal ACA Bil. convexity Clipping, hematoma evacuation present case 2000 62/M Headache, ptosis Lt. IC-PC Tentorium Clipping cerebelli
IC-PC: internal carotid-posterior communicating artery bifuration; ACA: anterior cerebral artery.
OUTCOME Good Death Good Good Good
86
Surg Neurol 2000;54:82–6
Ishikawa et al
reported to indicate a ruptured aneurysm of the distal ACA on CT [8,15]. In contrast, continuity between a tentorial hematoma and an ISH may indicate a ruptured aneurysm of the IC-PC junction [7]. The possibility of aneurysmal subdural hematoma should be considered in the absence of trauma.
13.
14.
REFERENCES 1. Ban S, Sato S, Yamamoto T, Ogata M. Distal anterior cerebral aneurysms causing acute subdural hematoma: report of two cases. Neurol Surg 1985;13:911– 6. 2. Bartels RHMA, Verhagen WIM, Prick MJJ, Dalman JE. Interhemispheric subdural hematoma in adults: case report and a review of the literature. Neurosurgery 1995;36:1210 – 4. 3. Bassett RC, Lemmen LJ. Subdural hematoma associated with bleeding intracranial aneurysm. J Neurosurg 1952;9:443–50. 4. Clarke E, Walton JN. Subdural hematoma complicating intracranial aneurysm and angioma. Brain 1953; 76:378 – 404. 5. Eggers FM, Tomsick TA, Lukin RR, Chambers AA. Recognition of subdural hematoma secondary to ruptured aneurysm by computed tomography. Comput Radiol 1982;6:309 –13. 6. Friedman MB, Brant-Zawadzki M. Interhemispheric subdural hematoma from ruptured aneurysm. Comput Radiol 1983;7:129 –34. 7. Hatayama T, Shima T, Okada Y. Ruptured distal anterior cerebral artery aneurysm presenting with acute subdural hematoma: report of two cases. Neurol Surg 1994;22:577– 82. 8. Ishibashi A, Yokokura Y, Sakamoto M. Acute subdural hematoma without subarachnoid hemorrhage due to ruptured intracranial aneurysm— case report. Neurol Med Chir (Tokyo) 1997;37:533–7. 9. Kondziolka D, Bernstein M, Brugge K, Schutz H. Acute subdural hematoma from ruptured posterior communicating artery aneurysm. Neurosurgery 1988;22: 151– 4. 10. McLaughlin MR, Jho H-D, Kwon Y. Acute subdural hematoma caused by a ruptured giant intracavernous aneurysm: case report. Neurosurgery 1996;38:388 –92. 11. O’Sullivan MG, Whyman M, Steers JW, Whittle IR, Miller JD. Acute subdural haematoma secondary to ruptured intracranial aneurysm: diagnosis and management. Br J Neurosurg 1994;8:439 – 45. 12. Pasqualin A, Bazzan A, Cavazzani P, Scienza R, Licata
15.
16.
17.
C, Pian RD. Intracranial hematomas following aneurysmal rupture: experience with 309 cases. Surg Neurol 1986;25:6 –17. Ranganadham P, Dinakar I, Mohandas S, Singh AK. A rare presentation of posterior communicating artery aneurysm. Clin Neurol Neurosurg 1992;94:225–7. Serizawa T, Satoh A, Kobayashi S, Nakamura H, Odaki M, Miyata A, Watanabe Y. Three cases of nontraumatic acute subdural hematoma. Neurol Surg 1991;19:1061–5. Watanabe K, Wakai S, Okuhata S, Nagai M. Ruptured distal anterior cerebral artery aneurysms presenting as acute subdural hematoma—report of three cases. Neurol Med Chir (Tokyo) 1991;31:514 –7. Weir B, Myles T, Kahn M, Maroun F, Malloy D, Benoit B, McDermott M, Cochrane D, Mohr G, Ferguson G, Durity F. Management of acute subdural hematomas from aneurysmal rupture. Can J Neurol Sci 1984;11: 371– 6. Zimmerman RD, Russell EJ, Yurberg E, Leeds NE. Falx and interhemispheric fissure on axial CT: II. Recognition and differentiation of interhemispheric subarachnoid and subdural hemorrhage. AJNR 1982;3:635– 42.
COMMENTARY
The authors are to be complimented for bringing to the readership’s attention a very unusual circumstance. This patient suffered acute hemorrhage from an irregular posterior communicating artery aneurysm that resulted in a subdural hematoma along the tentorium and falx. Angiographically, this aneurysm was very irregular and multi-lobulated and certainly seemed to climb up over the edge of the tentorium as depicted in the images. It certainly makes sense that adhesions of the fundus could result in acute rupture through the arachnoid directly into the subdural space. We should all keep this possibility in mind as we evaluate patients with acute symptoms and without a history of trauma. H. Hunt Batjer, M.D. Department of Neurological Surgery Northwestern University Medical School Chicago, Illinois
merican society is moving from the security of a belief in everlasting material progress (called modernism), based on the principles of Enlightenment as expressed through the successes of the capitalistic, democratic, industrialized nations, and is entering a time of confusion (called postmodernism), characterized by decreasing faith in the old principles and with no new governing paradigm readily available. Modernism has brought society many advantages, but it does not provide meaning or happiness in life.
A
—Roger J. Bulger, M.D. “The Quest for the Therapeutic Organization” JAMA 2000;283:2431–3